A clinical assault?

The practice of female circumcision in Indonesia has moved into hospitals. Greater genital mutilation is the likely result. Matthew Moore and Karuni Rompies report.

Hospitals across Indonesia
are offering new parents a
one-price surgical package
for their just-born girls —
as well as piercing their
ears, they'll circumcise
them.

At Jakarta's Hermina Hospital the
price for the two procedures is 95,000
rupiah (about $A16), at IDI hospital in
Surabaya in East Java it's only 15,000
rupiah, while in Makassar's Khadijah
Hospital in Sulawesi, hospital staff
quote 25,000 to 30,000 rupiah.

In some hospitals and health care
centres, vaccinations are also included
in the package as modern medicine
takes over a field long occupied by
traditional, village-based healers,
attracting parents with the
convenience of a one-stop shop.

While hospitals might be more
hygienic, health care experts are
worried by strong evidence that the
move has led to more of the child's
genital tissue being cut because
medical practitioners use different
implements and techniques.

Village-based midwives and
traditional healers have been
circumcising girls in Indonesia for
centuries, although the extent and
details of the practice are only now
emerging.

Two big studies have been published this year, with the
most comprehensive — Female Circumcision in Indonesia
, by the
Population Council — raising concerns
about the current move to
"medicalisation" in hospitals.

"Many maternity clinic midwives
have begun to market female cutting
(FC) as part of a birth delivery package,
with the service being offered to the
parents right after the delivery of a
baby girl," the report says.

"The danger of medicalisation of FC
lies in the fact that midwives tend to use
scissors instead of penknives, and thus
the tools used are for real cutting of the
clitoris (incision and excision) where
traditional providers more often use
penknives for more symbolic acts of
scraping or rubbing … ," the report says.

The professor of demography at
Australian National University, Dr Terry
Hull, worked on both studies — he first
came across female circumcision in
Indonesia 30 years ago when he lived
in a simple village near Yogyakarta
while researching infant mortality.
Back then he learnt about symbolic
circumcision, when he saw local
healers cut a turmeric root and rubbed
it on the baby's clitoris while chants
and prayers were uttered by those
attending.

"This was very much women's
business, and even if the fathers of the
girls were there, they would not
understand what was done," he says.
In the cities, where Islamic
influence was stronger, circumcision
involved drawing blood, usually by
putting a pin in the clitoris, Hull found.

Despite these and other related
practices, he says that in Java at the
time there was "universal denial" that
circumcision of females took place.
Even now, he says, there is a dearth
of good information because it is
generally deemed too sensitive a topic
to be openly discussed, or surveyed by
government departments. Mothers
have told him they do not know how
much flesh has been removed from
their babies during circumcision as
they often don't look.

Dyah Agusmunwati, 36, is such a
mother. She cited "tradition, religion
and health" as the reasons for
circumcising her daughter soon after
giving birth to her in a Jakarta hospital,
but was vague on the details about
what happened.

"I even don't have any idea of which
part of my daughter that was cut. She
was circumcised when she was a day
or two days old, I guess."

In an attempt to find out more
about female circumcision, the US
AID-funded study by the Population
Council surveyed 1694 households in
eight separate regions and found all
the boys and 97.5 per cent of girls had
been circumcised.

While circumcision is clearly
widespread in Indonesia, it is very
different from the female genital
mutilation (FGC) common in parts of
Africa that often severely damages
almost all genital parts.

While many questions about the
practice remain unanswered, the study
concluded circumcision in Indonesia
at present "did not reveal any clear,
immediate or long-term physical or
psychological complications . . . for
girls or women".

It listed the most common forms of
circumcision as "rubbing and scraping;
stretching, pricking and piercing;
incision; and excision", and the cutting
instruments used as "penknife;
scissors; bamboo knife/razor blade
and needles".

While blades of some sort have long
been used, traditional practitioners
often used a knife only to rub or scrape
in a symbolic exercise that often did
not draw blood.

The concern now relates to
changes due to circumcisions in
hospitals, where health care
professionals use scissors in more
than 75 per cent of cases, which
invariably means cutting flesh.

"One midwife in Padang (West
Sumatra) described how she usually
cuts the clitoris, either directly or by
pinching it first with tweezers and then
cutting the tip with scissors. Another
said she only scratches the clitoris."

Betadine is widely used after the
procedures, and infection has not
emerged as a major problem.
Because of the wide variation in
procedures used, the report was
unable to say how much (if any), flesh
was usually removed. But it concluded
that where tissue was excised, it was
generally a tiny amount.

It's not only babies who are
circumcised, with one-third of those
surveyed circumcised between the
ages of five and nine, and some even
older.

Several hours out of Jakarta in
Bandung, the Assalaam Foundation
has been holding free mass
circumcisions for males and females
for almost 50 years, with as many as
400 people turning up at a time.
Syarief Hamid, treasurer with the
foundation, which runs several schools, said the circumcisions were
timed to honour the Prophet's
birthday, and were growing in
popularity each year.

While religion is the main reason
for circumcising girls, he says there are
also health reasons.
"I understand that a girl who is not
circumcised would not have clean
genitals after she urinates and
sometimes that can cause cervical
cancer," he says. "The religious view is,
if you are not circumcised you won't
have clean genitals after urinating. If
then you pray, your prayer won't be
legal."

The practitioners who come from
the local hospital always cut a piece off
the clitoris, he says. Most of those who
were circumcised were babies, but
older people come, too.
"Sometimes there are also women
of 20 or 30. Even grandmothers aged
50 or 60 years old come."
Those who have the procedure
describe it as "like an ant bite" he says.

Health department authorities have
been on hand to observe, along with
representatives of the World Health
Organisation, and they have left
satisfied, Hamid says.

"What they saw here was different
to what they imagined, it was different
to what they saw in Africa."

While there's a clear religious reason
set out in the Koran for Muslim boys to
be circumcised, there's no such
imperative for girls, and Muslim
leaders, practitioners and parents all
struggle to provide clear answers on
why they circumcise girls.

Religion was the reason cited by 55
per cent of mothers surveyed for
circumcising their daughters, although
none could identify parts of the Koran
or the Prophet Muhammad's guidance,
called Hadith, where it is stipulated.
While 32 per cent nominated health
and hygiene as the perceived benefit, 9
per cent said they did not know what
benefit it would bring.

Masitoh Chusnan, from the
women's wing of Muhammadiyah, one
of Indonesia's two biggest Muslim
organisations, says circumcision of
girls is regarded in Islam as an
honourable practice.

"The Hadith did not say it's
obligatory, but it is recommended to
have it done," she says. "There is the
Prophet's words saying girls must be
circumcised, but you should not cut
too much."

Dr Laura Guarenti, the WHO's
reproductive health representative in
Indonesia, says the organisation does
not accept any genital cutting in
medical institutions.

Although there is still not a
complete picture of female
circumcision in Indonesia, Guarenti, a
gynaecologist with extensive
experience in Africa, is concerned
about the move to hospitals.

"The danger of medication is when
you have an instrument — it's easier to
use scissors and it can be harmful," she
says.

She adds, however, that
circumcision is an issue that can be
addressed only by Indonesian women
and not by outsiders.

"People should not judge this. It
should be clarified by Indonesians,
not by us. I am absolutely against
any female circumcision, but it's the
women here who have to do
something. And if it's just a ritual, it's
not necessarily a horrible thing just
because the genitals are touched."

While the reports conclude there
is no evidence of damage to girls
who are circumcised, the fact that it
is done without the consent of the
child, and without clear health
benefits or religious mandate, was
enough to classify it as a violation of
human rights, according to the
Population Council report.

The practice could be seen to
violate the rights of the child as
guaranteed under the Convention on
the Rights of the Child, ratified by
Indonesia in 1990.

Whether that's the case or not,
current practice shows no signs of a
decline in popularity, with more
than 90 per cent of mothers
questioned supporting the practice
continuing.

And one in five mothers even
suggested social sanctions should be
imposed on girls who were
uncircumcised.